I wanted to post my thesis that I wrote in my final year of college. I feel that the findings from my research are still very relevant today. Even before I became pregnant, I had interest on how the media has huge power over shaping our interpretation of pregnancy, childbirth and motherhood. I know it is long…..but even scrolling through the sub headings may be of interest for some of you.
Introduction and Background
The purpose/aim of this paper is to explore the existing literature of media representation of pregnancy, childbirth and early motherhood on pregnant women and mothers. According to the findings of a UK survey of 2101 women by Redshaw et al. (2006), only 45% of pregnant women attended structured antenatal education classes. This figure is in line with the Listening to Mothers || survey of 1573 women where only 25% reported going to antenatal education classes (Declercq et al.2006). Based on these figures one must question the source from which women are retrieving information, other than their healthcare professionals. As noted by Young (2010) pregnant women worldwide are seeking and accessing information to complement that obtained from antenatal education classes via the Internet, television, books and magazines.
The growing popularity of television shows such as “One Born Every Minute” raises questions of their impact on women and the choices they make during pregnancy. These choices concern the location of their birth, how they will feed their baby, and the provision of their care during pregnancy and childbirth. As highlighted by Morris & McInerney (2010) from an analysis of reality based TV shows, the media illustration of childbearing and labour is often inaccurate and lacks evidence . How does women’s exposure to factually incorrect information influence them? Langan et al. (2010) found that 94% of women access the Internet to supplement information they received from their healthcare provider. Women tend to use the easily accessible online information over antenatal classes. The media therefore acts as a convenient alternative to childbirth education classes, which is particularly important for women who perhaps live in rural areas who cannot access frequent antenatal classes. Types of media which influence the choices of pregnant women include television, the internet, magazines and advertisements (Theroux 2011).
Are they being influenced by things such as celebrity culture, fads, or advertising bias?
My interest in this topic developed from writing a previous piece based on a Health Service Executive (HSE) website “whatsupmum” (HSE 2012), which is intended to act as an educational website for mothers. It focuses on pregnancy, childbirth and the postnatal period. This website raised questions and concerns for me as to how much influence the media has on pregnant women. From reviewing the website, I was made aware of the potential effect the media can have on women in relation to the choices they make during pregnancy childbirth and early motherhood. I felt that the literature about media representation of pregnancy was compelling. I also believe that the topic has serious implications for midwifery practice, and maternity services at large. According to Langan et al. (2010) based on a sample of 613 women from 24 countries, 97% accessed the internet for pregnancy related information, while 94% used the internet to supplement information gained from their care provider, indicating the popularity of online media. The use of internet as a means of education for expectant mothers is of great significance for midwives. Out of 1,573 mothers in the United States who participated in a study by Declercq et al. 2006, only 53% of first time mothers attended antenatal classes, while only 9% of experienced mothers attended.
Morris and McInerney (2010) examined the impact of reality based television programmes on women. They used a qualitative descriptive approach to examine two popular reality shows, one being “A Baby Story” and the other “Birth Day”. They found that birth was depicted as something potentially hazardous and in need of medical surveillance. Women’s bodies were portrayed as inferior, and in need of technology and intervention in the hospital setting in order for childbirth to be safe. This is an untrue depiction as we know from the work of Devane et al. (2007). Morris and McInerney (2010) also found that caesarean section was alluded to as common practice, alongside breech birth being misrepresented with a 14% incidence, while in reality it has a typical rate of 3-4% (Theroux 2010). These types of programmes perhaps act more as scare mongers for pregnant women, rather than offering insight into what pregnancy and childbirth is like for the majority of healthy women.
According to the Listening to Mothers II survey, two thirds of women regularly watch reality based television to broaden their knowledge of pregnancy and childbirth (Declercq et al. 2006).It is clear that the popularity of websites and television programmes focusing on pregnancy and birth is ever mounting. This popularity is applicable for magazines and advertisements alike (Young 2010). As midwives it is imperative that we correct the misinformation provided by the media for women. The information offered from these sources can potentially be out-of-date, biased, not strictly based on evidence, inaccurate or indeed, dramatized. Similarly, for the likes of magazines, use of language and text may present information incorrectly therefore controlling information (McIntyre et al. 2011), which potentially controls women’s choices and knowledge about pregnancy and childbirth.
A search was conducted using online databases such as CINAHL, MIDIRS, Pubmed, PsycInfo, Google Scholar and FACTfinder alongside published literature from the library. Key words were used and adapted for each database. Key words used included ‘pregnancy’ ‘child bearing’ ‘pregnant’ ‘pregnant women’ ‘media’ ‘media industry’ ‘media influence’ ‘online education’ ‘internet’ ‘television’ ‘media resources’ ‘women’s choice’ ’women’s attitudes’ ‘maternal choice’. Key words were linked using ‘AND’ alongside ‘OR’ to ascertain the results were relevant, and that they focused on the topic. From the results, articles were further screened for relevancy via abstract. The search was limited to literature reviews, peer reviewed journal articles, randomized controlled trials, internet articles, magazines newspaper reports and television programmes (both reality based and fictional). Inclusion criteria were English language, related to humans, and pregnancy and women focused. Relevant articles were screened further via full text to further assure the content was of focus for the topic.
Articles published from the past 10-15 years were sourced to ensure evidence was up-to-date, yet was able to ascertain growing trends/themes. On further evaluation of the included material, references from a wider time scale were included, for example Young (1990) and World Health Organisation (WHO) (1981) due to the numerous references made in newer texts.
A snow ball search was also employed whereby a hand search of reference lists from relevant articles was also conducted to ensure that other relevant literature was also identified. It is hoped that this paper will offer insight into the information circulating in the media lending particular concern to the themes outlined. This paper will discuss the existing literature on how the media portrays body-image in pregnancy and place of birth and the role of the midwife, and breastfeeding. These themes were chosen as they have been repeatedly highlighted in the existing literature explores.
Portrayal of Body Image
According to Devane (1996) body image is an internal depiction and perception of one’s external appearance. Body image appears to affect pregnant women in ways similar to the embarrassment experienced by some from breastfeeding in public; which will be discussed later in this paper. Devane (1996) acknowledges how the western world is consumed with print mass media. This perhaps reflects women’s growing quest for seeking what is ‘on trend’ or what looks ‘perfect’. The media bombards the public with images that dictate what the ideal female body type is, thus potentially having adverse effects on women’s self- esteem (Abraham 2005). Pregnant women are particularly vulnerable to having low self-esteem with regards to body image during the first and second trimesters when the body undergoes vast physical changes (Devane 1996). These changes include enlarged breasts and abdomen, and perhaps the appearance of straie gravidarum. These changes potentially can make women feel less attractive or uncomfortable. Indeed, it should be understood that such vast changes in a short space of time i.e 9 months, can be very hard to adapt to.
According to Gow et al. (2012) women are conditioned to view themselves as sexual objects that are scrutinized by others based on outer appearance. This point may be irrelevant for some women however it is noteworthy as the media have gone obsessive with body image and body surveillance, particularly for the pregnant or postpartum woman. It is very hard nowadays to pick up a magazine that does not contain dietary advice, or an analysis of celebrities’ bodies (Miriam 2011). Continuous self-judgement is associated with shame about appearance and bodily functions such as breast feeding, as suggested by Moradi & Huang (2008). Kitzinger & Kitzinger (2001) highlights that the media tends to communicate pregnancy and childbirth as an experience that yields embarrassing consequences such as stretch-marks, saggy breasts and increased weight. It is concerning to see that the HSE (2012) whatsupmum website employed advertisements preceding their educational videos – for stretch-mark lotion. The inclusion of such an insensitive advertisement is only bound to make women feel more paranoid about their stretchmarks being somewhat unsightly and therefore they should make an effort to remove them with such products (Roth et al. 2012).
A study by Gow et al. (2012) explored the impact of three popular entertainment magazine websites that are accessed by 13 million people per month; these being People, U.S Weekly, and Star. The study was based on 387 online articles published between 2007-2008 focusing on celebrities’ pregnancy and postnatal bodies. Online versions of the articles were chosen as they are easily accessible and free of charge. Articles were coded into categories for example ‘Postpartum body dissatisfaction’. It should be noted that bias is perhaps evident in this study as coders of the articles were not blinded to the aims of the study; those being to evaluate the portrayals of celebrity weight and body shape in pregnancy and the postnatal period. The authors found that pregnancy weight gain is depicted as something negative (n=44%) or is communicated in the neutral (n=44%). Pregnancy weight gain was often associated with language such as “piling on the pounds” (Gow et al. 2012, p.4). A focus of weight loss methods in the postnatal period appeared popular in the magazines also. The magazines featured negative discussion such as “baby bulge gone” and “body bounce back” (Gow et al. 2012 p.4). These articles are somewhat concerning given that according to Rasmussen & Yaktine (2009) the amount of pregnancy weight gained by these celebrities was within normal limits; yet still depicted as negative. Articles focusing on postnatal weight loss may also lead to unrealistic expectations for the average woman, and therefore put pressure on her to conform to the ideal postnatal body according to mass media. According to Rallis et al. (2007) women report feeling dissatisfied with their postpartum bodies. According to a survey conducted by Slimming World based on 1015 new mums, 31% of women reported feeling under pressure to lose baby weight from the media, while 38% were tempted to use quick fixes or fads to lose their baby weight (Royal College of Midwives 2013) (RCM). Given the media’s significant coverage focusing on celebrities experiences of childbearing and the postnatal period, it could be suggested that this coverage acts as a means of comparison for women who are pregnant or in postnatal period at the same time as those highlighted in the media.
A small study conducted by Hill et al. (2013) of 108 pregnant women used a reliable Body Attitudes Questionnaire during each trimester of pregnancy to measure body image perception. A similar study using this reliable questionnaire was also conducted by Skouteris et al. (2005). Hill et al. (2013) found that women who had a negative attitude to weight gain in pregnancy tended to gain less weight in pregnancy. Feelings of unattractiveness in pregnancy, however, appeared to yield higher levels of weight gain. It could be suggested that inevitable weight gain in pregnancy may lead to women feeling unattractive and therefore gaining more weight in pregnancy. It should be noted that due to the small size of this study, findings are not comparable for most women.
The media appears to heavily focus on the postpartum body ‘bouncing back’ after pregnancy. Roth et al. (2011) notes how magazines and the media often discuss postnatal celebrities’ bodies bouncing back as if from illness. This therefore leads to the female body being depicted as unnatural. This argument has also been highlighted in the literature by sociologist Jeffries (2007). At the time of writing this piece there has been significant interest and media coverage surrounding the birth of the royal baby Prince George. Speculation surrounding the Duchess of Cambridges’ weight gain, and weight loss plans for the postnatal period, have been rife. In an article titled “Weighty issue for celebrity Mums” in a popular Irish weekend magazine Star Chic, the author explores the various weight-loss methods used by celebrities, and highlights how much weight each celebrity gained in pregnancy. For example Jessica Simpson and Isla Fisher gained “70 pounds” (Hogan 2013, p.10). Kate Middleton the Duchess of Cambridge is described as having a “mummy tummy” and is praised for stepping out one day after having her baby without pretending that she “pinged back into shape overnight” (Hogan 2013 p.10). It is worrying that a magazine feels the need to analyse any woman’s weight during or after pregnancy. The article goes on to address “How Big Should Your Bump Be?” which examines the ‘normal’ amount of weight that should be gained for different ‘body types’ (Hogan 2013, p.10). This again highlights to women what is normal or acceptable in society. The article also uses pictures of each celebrity during pregnancy, again implying what looks good and what does not. Mcnamara (2006) acknowledges how these images of celebrities blatantly send messages about what the ideal pregnant and postnatal woman should look like.
Gow et al. (2013) acknowledges that the idealized postpartum celebrity image is not easily attainable for the everyday woman. Celebrities have access to personal trainers, dieticians, and can above all afford childcare in order to dedicate the time to ‘ping’ back into shape (Gow et al. 2013). Hummerston (2013) also notes this in her piece “The pressures of modern pregnancy,” where she discusses the birth of His Royal Highness Prince George. She notes the scrutiny endured by Kate Middleton throughout her pregnancy, which included analysis of the size of her bump and of her fashion choices throughout pregnancy. Hummerston (2013) is of the opinion that the media puts the everyday woman under pressure, as it bombards women with idealised images of pregnant celebrities who appear to have had their babies and lost any excess weight in a remarkably short space of time. This piece refreshingly highlights the important role of the midwife; stating that women need a supportive healthcare provider to ensure a healthy pregnancy and to provide calming support and reassurance if women are feeling under pressure to look a certain way. An Australian study by Roth et al. (2012) analysed a purposive sample of 58 magazines addressing postnatal celebrities’ weight loss. The authors acknowledged 6 themes using Jeffries analytical techniques which included “perfection and attraction”, “enumerating and exemplifying” and “assuming and implying” (Roth et al.2012). The authors found there was a heavy emphasis on depicting the ‘exemplary mother’. Similarly to the article by Hogan (2013) in Star magazine, Roth et al. (2012, p.4) found that there was frequent use of terms such as “belly bulge”, “yummy-mummy”, “post baby body”, “trim” and “ toned”. This was also noted by Hummerston’s (2013) description of Kate Middleton’s media coverage during and after her pregnanc. The author noted how the first pictures of the Duchess after giving birth were followed by a flurry of articles speculating when she would begin her quest to return to her pre-pregnancy shape. The picture in question is of a totally natural postnatal stomach. It is discouraging to think that we now live in a world in which the media would confront a woman over her physiological return to her pre-pregnant body. It could be argued that the media spoiled the news over the birth of the royal baby by reducing it to a concern over the Duchess of Cambridges’ weight.
Authors acknowledge that the use of language in some articles implied that pregnancy is a somewhat unnatural condition which drives women to eat uncontrollably. The use of words such as “gorged” gives the sense of a pregnant woman being a mindless creature whom is powerless over her desire to eat (Roth et al. 2012, p.131). It would appear from the pieces quoted in the paper that self-control is only redeemed in the postnatal period. This information is not transferrable to every woman however it is communicated as the norm. In relation to breastfeeding, the authors noted how it was more so discussed as a weight loss strategy employed by celebrities rather than a natural instinctive choice (Roth et al.2012, Budin 2011). Discussions surrounding breastfeeding omitted the health benefits for mother and baby but rather highlighted it as a weight loss method for celebrities. This raises concern that breastfeeding is more so being promoted for its weight loss effects rather than for its numerous health benefits.
The obsession to achieve the pre-pregnant body in a short space of time is apparent in mass media (Doughty 2013, Abraham 2005). In a piece published in 2005 for New York Magazine, Laurie Abraham (2005) writes about New York women’s frantic quest to remain thin whilst simultaneously reproducing human life. The piece addresses how obsessing over one’s dress size during pregnancy is merely just an act of consciousness. Doughty (2013) reports in New magazine how reality television star Kim Kardashian allegedly feels under pressure to lose her pregnancy weight of four stone in six months. This appears to be a very short time frame for such an amount of weight loss. Abraham (2005) acknowledges how some women are using online blogs and social media to discuss and compare weight gain via online weight polls. She discusses how women share tips and advice online; such as it being ok to exercise once the heart rate does not reach 140 beats per minute. This information is potentially dangerous for any high risk woman to read, however it is alluded to as safe. The concern raised by these online forums, which are accessible 24/7, is that the information shared through them may simply be word-of-mouth, and not based on any evidence (Theroux 2011). The source of the information may rarely be questioned. Abraham (2005) then goes on to acknowledge how a woman replied to this advice by setting herself a target to get to 137 beats per minute as “that’s the type of person I am” (p.2) . This may suggest that women these days are getting to the point where they are willing to gamble their babies’ wellbeing in order to control their size during pregnancy as they are tormented by messages and images in the media suggesting that ‘thin is in’ (DiPietro et al. 2003). It was interesting to note the impact of ‘fat-negative’ messages in the media on a previously ‘fat-positive’ country that is Fiji. In the past, Fijian women’s body shape was not scrutinized (Becker et al. 2007). Within three years of the introduction of television to the island, Fijian women were found to be more at risk of body-dissatisfaction (Becker et al. 2007). This may therefore suggest the media is a powerful influence on women’s body-image, leading to body dissatisfaction.
The pregnant and postpartum body is communicated as somewhat troublesome or as a work-in-progress (Roth et al. 2013). This was portrayed in magazines such as Closer, where headlines such as “I have cried and sweated to get my size 10 body back” (White 2013, p.74-75) filled the pages. This article centres on an interview with a reality TV star in which she explains how she felt under pressure to lose her baby weight quickly after giving birth. This issue was also explored by Abraham (2005) as she compares leaving the hospital in the jeans you wore before pregnancy as a ‘medal’ or ‘badge of honour’.
A cross-sectional observational study by DiPietro et al. (2003) using factor analysis, Pearson correlations, t- tests and analysis for variations, examined women’s attitudes to weight gain in pregnancy at 36 weeks gestation. A total of 130 low risk pregnant women participated in the study with formal written consent. The findings showed that 21% of the women embarked on at least one weight restrictive behaviour in pregnancy. This was surprising given that the authors noted that majority of participants were relatively affluent, well-educated women; which is generally associated with weight gain within normal ranges (DiPietro et al. 2003, Caulfield et al. 1996) not weight restriction. The authors also found that of the women who gained weight within normal ranges, 37% were consumed with anxiety over gaining weight and getting ‘fat’ by the end of their pregnancy. The word ‘fat’ is acknowledged by Bordo (2003) as a form of deviance from western society and is associated with assumptions of failure, neediness and laziness (Bordo 2003). Most worrying however, was the finding that 11% of women who under gained felt that the weight they did gain made them feel unattractive and anxious.
There is strong evidence to suggest that the media play a part in increasing the level of anxiety experienced by women in relation to body image during pregnancy and the immediate postpartum period. The assumption is that to be thin is to be attractive and therefore acceptable and ‘normal’. So how are women who do not fall within this restrictive parameter perceived? It is crucial as midwives that we acknowledge the pressures women may feel and offer support and advice where necessary, as the potential for depression from body dissatisfaction may occur for some women.
Portrayal of Breastfeeding
According to Brown & Peuchaud (2008) the media is responsible for communicating what is normal and socially acceptable. The media representation of infant feeding has been interpreted in different ways. This is similar to interpretation of body-image in pregnancy as previously discussed. On one hand, a number of authors have noted that the media have created bottle feeding as normative behaviour, while breastfeeding is often illustrated as something difficult and inconvenient (Brown& Peuchaud 2008, Kitzinger & Kitzinger 2001). On the other hand, Frerichs et al. (2006) and Young (1990) are of the opinion that the media attempt to portray breastfeeding in a positive light, however often highlighting the difficulties associated with it. It would appear from research that exposure to breastfeeding in the media would increase awareness and perhaps normalize it in the public, just as bottle feeding exposure in the media has constructed it as normal “acceptable” behaviour (Foss 2010, 2013). This section of the paper will address the sexualisation of the breasts in the media and the implications of this on the representation of breastfeeding in the media. The portrayal of breastfeeding in contrast to that of bottle feeding will also be discussed.
Despite the WHO (1981) code of marketing that forbids endorsement and advertising of formula milk as a superior alternative to breast milk, the advertising of toddler follow on milk is not banned or restricted. According to a study on behalf of the Australian Breastfeeding Association by Berry et al. (2011), parents perceive advertisements for follow on milk as the same as those for infant formula due to brand affiliation with both milks. Therefore it could be suggested that because of the association between newborn infant formula and follow on milk under the same branding; women perceive formula feeding as normal and safe. It is also worth noting that a recent qualitative textual analysis by Foss (2013) based on 53 fictional representations of breastfeeding from 1974-2012 identifies that the representation of breastfeeding has become more common in recent years. This finding is refreshing given that over a month-long television sample, only one scene depicted breastfeeding, which contrasts significantly to the 170 depictions of bottle feeding viewed (Kitzinger & Kitzinger 2001). It was positive to read from Foss (2013) that popular TV shows such as Friends, Two and a Half Men and The Big Bang Theory have all aired portrayals of breastfeeding. However, length, level and nature of exposure are not mentioned; so it could be argued that the portrayals might not fully have the desired effect on pregnant women and mothers.
Breastfeeding is often inaccurately depicted in the media. Foss (2010) conducted a qualitative study examining 237 issues of the popular Parents magazine from the years 1930-2007. This extensive study explores the infant feeding discourse over 79 years. It demonstrates that breastfeeding is often misrepresented; an aspect of its inaccurate depiction being that it is painful. Literature concerning breastfeeding exposed that the sexualisation of breasts in mass media has adversely affected the perception of breastfeeding (Foss 2013, Bartlett 2005, Stewart Knox 2003, Devane 1996). Further reading also highlighted that the media lacks evidence based information on breastfeeding therefore it is unable to offer women practical information concerning problems such as cracked nipples and mastitis. Much of the literature indicates that media’s address to breastfeeding highlights the issue of people’s discomfort whilst in the company of breastfeeding women, this discomfort being as a result of the association between breasts and sexuality (Symonds & Hunt 1996, p.118). Therefore it could be assumed that the media is partly responsible for making this response normal and passive (Foss 2013, Barlett 2005, Kitzinger & Kitzinger 2001)
As previously mentioned, the media holds the power to construct behaviour in society. In relation to this, data from the Infant Feeding II study (Fein et al. 2008) based on a convenience sample of 3033 participants, showed that women who were exposed to little or no media portrayals of breastfeeding were least likely to initiate breastfeeding (78.1%) or continue to breastfeed at two months postnatal (53.0%). Kornides & Kitsantas (2013) came to a similar conclusion from their study which examined how antenatal exposure to breastfeeding in mass media influenced breastfeeding outcomes. The authors findings were based on data from the Infant Feeding II study (Fein et al. 2008) alongside a cohort of US women. Kornides & Kitsantas (2013) used chi-square, descriptive statistics and logistic regression to form the opinion that knowledge is power for women in order to initiate breastfeeding. They found that women who were exposed to breastfeeding information via mass media were 11.2 times more likely to initiate breastfeeding (95% CI: 6.87-18.45). This finding is not surprising given that Kitzinger & Kitzinger (2001) and Henderson et al. (2000) reported on the vast discrepancies between bottle feeding and breastfeeding portrayals on television. Foss (2010) is also of the opinion that bottle feeding predominantly features in popular print media, with breastfeeding receiving little attention in comparison. The findings of Kornides & Kitsantas (2013) are similar to those of Arora et al. (2000), which indicated that bottle feeding mothers would have been more likely to breastfeed if their level of media exposure to breastfeeding was increased. The level of exposure to bottle feeding information from print or websites tends to lead to a higher rate of bottle feeding initiation, as found by Zhang et al. (2013).This study was based on a sample of 2530 participants using negative binomial logistic regression and survival models to measure the influence of antenatal exposure to formula milk advertisement and initiation. As these findings raised concerns for me, I decided to conduct my own casual research on the portrayal of breastfeeding in mass media in comparison to that of formula milk. Over a random sample day I counted seven advertisements for follow on formula milk (of which brands are affiliated with infant formula milk). I found no televised advertisements promoting breastfeeding.
The Irish National Infant Feeding survey revealed that 39% of women in Ireland have experienced problems with relation to breastfeeding in public (Begley et al. 2008a). 11% of these women shared how they were forced to stop breastfeeding as they were made feel embarrassed for breastfeeding in public (Begley et al. 2008a p.142-143). The exposure of a women breastfeeding in public does not harm anyone, however it is grudgingly condoned (Blum 1999). This raises comparisons in one’s mind between people’s attitude towards women breastfeeding in public and their attitude towards people smoking in public. Has a smoker ever been forced to stop smoking in public because they felt “embarrassed?” Smoking in public has become so common that people react passively towards the potential harmfulness of second hand smoke. Whereas, as pointed out by Blum (1999), breastfeeding inflicts no harm, yet it receives negative public reaction.
The embarrassment associated with breastfeeding in public appears to predominantly affect Irish women, as described by Begley et al. (2008a). When the authors of the study divided participants into ethnic groups, 49% of Irish women would breastfeed in public in contrast to 63% from other ethnic backgrounds (Begley et al. 2008a). This may be due to the fact that breastfeeding is not shown or discussed as frequently in Irish media in comparison to other countries. However, this may also indicate a cultural issue. Zhou et al. (2010) explores the idea that women predominantly feel uneasy breastfeeding in public as they view the breasts as sexual objects. Zhou et al. (2010) used a cross-sectional self-administered survey based on 343 women. Over 65% of the women disclosed that they would feel embarrassed to breastfeed in public. It is perhaps strange to think that semi- exposed breasts; for example models in bikini tops, is acceptable or passively used in mass media and advertising, yet women are left feeling awkward while breastfeeding in public. The same area of the breast is covered up by both a bikini and a baby. So the question of why women feel this way remains.
The sexualisation of the breasts in film, advertisements, magazines and video games has been prevalent in the past six decades (Dickermann et al. 2008). Much of this sexualisation occurred throughout the 40’s, 50’s and 60’s. This resulted in breast milk to be viewed upon as something “dirty” (Blum 1999, p.41). Foss (2010) noted that Parents magazine did not feature breastfeeding between 1930 and 1949. Parents magazine has a readership of over 2 million and according to the Audit Beureau Circulations (2009) and Magazines for Libraries 2003) is one of the leading publications for parenting. Therefore the unanimous view of breastfeeding as “dirty” throughout the thirties, forties, fifties and sixties is unsurprising. The author noted that throughout this period, the editors heavily promoted the idea of modern medicine and regarded breastfeeding as a somewhat historic act. Bottle feeding was depicted as an act that was advised by unnamed “experts”. Formula milk was promoted as nutritionally superior to breast milk, which we know today, is not factually accurate (Kitzinger & Kitzinger 2001). I found it intriguing that a more recent study from Berry et al. (2011) using semi structured interviews with formal consent, found that mothers frequently read the ingredients of formula milk. However, they do not understand the majority of those listed, yet continue to feed it to their babies. It appears that even today some women may still rely on that “expert” opinion, as communicated by the media, without questioning it. It should be noted, however, that this particular study was exploratory in nature with a small sample size and therefore findings cannot necessarily be applied to a wider population.
Foss (2010) also highlighted in the study that no images of breastfeeding were shown up until 1955. Despite this, images of bottle feeding dominated the magazine until the 1990’s. It was from this time that breastfeeding rates appeared to increase perhaps due to the increase in publicity via articles and images in mass media (Foss 2010). This increased exposure may have led to women’s curiosity and desire to breastfeed. Despite the increased intention to breastfeed, the media portrayed breastfeeding as either: troublesome, inconvenient and isolating, or the polar opposite, as natural, easy, and trouble-free (Foss 2010). These vast discrepancies led to woman having false expectations. As noted on the ‘whatsupmum’ website (HSE 2012) practical information, such as the importance of positioning and attachment, is lacking. The media appears to present women with a list of possible problems women may face when breastfeeding, but offers no information such as the use of colostrum for cracked nipples, or the importance of cold and warm compresses (Foss 2013, Kitzinger & Kitzinger 2001). This may lead to women giving up breastfeeding once they encounter such issues, as they may have envisioned breastfeeding to be problem free. Therefore, they may feel as if they have failed. Depicting breastfeeding as plagued with problems such as cracked nipples and saggy breasts without offering support will discourage women from considering it.
Stewart-Knox (2003) acknowledges that breastfeeding in the media is often portrayed as something socially isolating. This could be responsible for women feeling as though breastfeeding is not something they should do outside of the home. In the study conducted by Stewart-Knox (2003) using focus groups complied of 12 women who were asked to comment on pictures used for breastfeeding campaigns. The main comments were that the women in the pictures were semi-naked, indoors, and alone. This suggests the idea again that breastfeeding is an isolating activity. Some television advertisements present breastfeeding as almost prison like. This was noted with a popular follow on milk advertisement, which shows a woman at the beginning of the ad breastfeeding indoors, alone and in a darkened room. The advertisement then continues to show the woman choosing follow on milk; suddenly she is outdoors in the sunshine playing and smiling with her baby. This particular advertisement may allude to the idea that that the decision to use formula is the same as a decision to buy some freedom. It is little wonder that media depictions appear to act as a deterrent for breastfeeding (Kitzinger & Kitzinger 2001).
On a more positive note, Wolynn (2012) acknowledges the potential that social media may have to promote and share evidence- based breastfeeding information. Wolynn (2012) highlights how today’s generation of mums have access to social media via smartphones, computers and tablets. He acknowledges how today Facebook has 900 million users, alongside Twitter with 500 million. Wolynn (2012) addresses the need for breastfeeding advocacy via social media as the potential to share evidence based information with such a vast audience is an extremely positive thing. However, social media has not yet fulfilled its potential with regard to this; mass media continues to dominate influence on the choices of mothers.
Place of Birth and the role of the midwife
Place of birth is another issue that is hotly debated in the media. Women’s concerns over where to give birth, and who will be their primary care advisor appear to be influenced by their exposure to social media, television, and magazines (Budin 2011, Young 2010). This is similar to the concerns raised over body-image and infant feeding from the media. Romano et al. (2010) acknowledges how women are exposed to multiple sources of information regarding pregnancy and birth. Indeed, mass media has the potential to instil confidence or anxiety in women regarding birth choices and care providers (Dahlen 2009, 2010). This is a cause for concern given that an increased access to multiple sources of information may lead to women utilizing information which lacks evidence or not adequately critiqued by healthcare professionals and therefore not beneficial to them. A study commissioned by the Kaiser Family Foundation exposed worrying trends with regard to the quality of reporting regarding healthcare in the media (Schwitzer 2009). Schwitzer (2009) revealed how journalists during an interview admitted that budget constraints are leading to poor coverage of healthcare news. The competition between media to break stories first puts journalists under immense pressure with regard to reporting within a very short timeframe. Therefore, a lack of critique occurs which leads to important details being omitted (Schwitzer 2009). It is because of this that healthcare professionals such as midwives must be up-to-date on healthcare news reports as they break in order to enable them to dispel myths or fill in the gaps of incomplete news reports. A qualitative phenomenological study using semi-structured interviews by O’Hare and Fallon (2011) highlights the need for midwives to have a sound knowledge of the information circulating in order to support women to make informed decisions on the best available evidence. The authors used a purposive sample of 9 women with inclusion criteria being over 18 years of age, primigravid mothers that were 6 weeks postnatal by the time the study commenced. The study aimed to gain insight into factors that influence women’s interpretation of control during childbearing and labour. The noteworthy limitations of this study are the small sample size and bias due to the women knowing that the authors were from a maternity hospital (Parahoo 1997). The use of purposive sampling may have led to bias as it is selective, subjective and non-probable. Results therefore cannot be generalised to a sample outside of the one used in the study.
Kitzinger & Kitzinger (2001) explore childbirth depiction in the British media. They noted how television programmes use male obstetricians to assist women during childbirth of midwives. The obstetrician is portrayed as the dominant character; a reproductive scientist as Prospero – in contrast to the midwife who’s role is often downplayed (Kitzinger and Kitzinger 2001). This was also noted by Dahlen & Homer (2012) who analysed 1086 web-based news reports on midwives (n=522) and obstetricians (n=564) over a twelve month period. They used content quantitative analysis to digest the data using Krippendorff’s approach to content analysis (Krippendorff 2004). The authors found that obstetricians are generally regarded as the experts while midwives were depicted as working in a struggling profession hampered by litigation and legislation. This imbalance was also noted in an Irish Times article by Browne (2010) whereby praise is given to one single obstetrician for working endlessly to improve Irish maternity services. One would wonder if the improvements reported were possible without the work of midwives. McIntyre et al. (2011) notes how such representations could lead to the untrue discourse that babies are normally delivered by male obstetricians. Kitzinger and Kitzinger (2001) highlight how in fact midwives assist in the birth of 68% of UK babies; based on statistics from The RCM (2000). It should be noted however that this figure has undoubtedly changed since the publication of that article. It is refreshing to see the emergence of shows such as One Born Every Minute and Call the Midwife in more recent years as they appear to put the role of the midwife in the spotlight.
The media has sensationalized and dramatized the whole experience of childbirth (Theroux 2011, Kitzinger & Kitzinger 2001). Childbirth is presented as a medical emergency that is preceded by the sudden onset of agonizing pain that leads to a rush for an ambulance to get straight to the hospital for delivery (Kitzinger & Kitzinger 2001). In relation to this, the ‘whatsupmum’ website (HSE 2012) employs a male obstetrician to present videos that discuss labour and childbirth in the hospital environment. There is neither mention of the word midwife nor midwifery led care, or indeed homebirth throughout the video, yet this website is aimed to inform Irish women of the Irish maternity services available to them. It would appear there is a control over the information shared on this website. Theroux (2011) noted from her study that television is often a scare monger for natural birth. This was also noted by Kitzinger & Kitzinger (2001) when discussing the storyline of childbirth on the popular US drama ER. The authors discuss how the woman at the centre of the storyline who wished for a natural birth experiences a shoulder dystocia, followed by an emergency caesarean section, haemorrhage and subsequently has a seizure and dies. It is shows such as this that encourage women’s fear that their bodies are not capable to give birth unassisted by medical intervention (Wagner 2001). Women may feel from watching these dramas that the risk of such emergencies are far greater than what is evidently accurate, which may lead to mis-informed decisions to be made. Television has indeed created an influential mythology of childbirth and the role of the midwife (Kitzinger & Kitzinger 2001). These types of dramas very often use doctors as the lead professionals in situations as described above. This may also be true in the majority of real life obstetric emergencies; however, this lends to discourse among women that it is only doctors that are skilled enough to deal with life and death situations and that midwives are not skilled or trained to deal with such cases (Seale 2003). This may lead women to opt for obstetric-led care purely as a precautionary measure. Birth is reinforced in mass media as risk paradigm; with obstetricians being the only professional with the expertise to deal with any obstetric emergency (Dahlen & Homer 2012).
Rogers et al. (2012) explores how the media communicated evidence from the Birthplace Study (Birthplace in England Collaborative Group 2011). The findings were published in November 2011 and were eagerly awaited by midwives and women alike. For women it meant their choices for place of birth had the potential to be expanded or restricted; for midwives it had the potential to highlight their role as the lead professional in maternity services (Rogers et al. 2012). The results showed that women choosing to give birth in an obstetric led unit were three times more likely to have an emergency section, and twice as likely to have an instrumental birth- in comparison to women who gave birth under midwife led care (Birthplace in England Collaborative Group 2011). Biased versions of the results were presented in the media however blurring the results and neglecting to report on key findings. For example, BBC News (2011) used headlines such as “Women should not have right to home birth if at risk” and “Home birth ‘carries higher risk’ for first time mothers” (Rogers et al. 2012, p.29). The evidence surrounding lower intervention for women who opted for a homebirth or a midwife led birth was somewhat ignored. It would appear that despite clear evidence in the study promoting midwife led care, the media remained in control of what results would be shared. Perhaps it could be speculated that the mothers and pregnant women who saw the news report, may never have questioned the bulletin, and therefore remain uninformed to the results and evidence from the study .Similarly, Budin (2011) discusses in her piece ‘Role Models for Pregnancy, Birth and Breastfeeding’ that positive media accounts surrounding natural birth are perhaps a source of inspiration for women to opt for a natural, safe and non-interventional birth. Budin (2011) acknowledges how actress Jessica Alba described in a magazine interview that she chose ‘Hypnobirthing’ and that she laboured at home. She described how she meditated and felt calm throughout (Schafer 2010). Similarly Budin (2011) comments on the season finale of the popular U.S reality television show Keeping Up With the Kardashians; whereby Kourtney Kardashian gave birth before an audience of 4.8 million TV viewers in a calm serene fashion (Gates 2010). The depiction of birth as a normal human physiological process via mass media to such a considerably large audience is a positive move. Similarly The Irish Times published a piece from a mother Elaine Byrne who discussed her experience of midwife-led care in Drogheda. Byrne’s account was positive; she described the birth as “fantastic” (Byrnes 2008, p.11). This is in stark contrast to findings from Morris and McInerney (2010) based on two television shows which presented birth as a risky, unpredictable event that warrants a hospital environment with medical intervention. The authors noted how women are depicted as powerless and inferior- a world away from the aforementioned account from Jessica Alba’s natural hypnobirth. The stance on the portrayal of homebirth in the media appears unbalanced. Kitzinger and Kitzinger (2001) comment on how depiction of home birth on television represents it as an historic act, or occurring as an accident which results in a negative outcome- such as the death of a baby. Television depiction of non –medicalized birth is largely absent whereas use of technology in a hospital environment is rampant (Morris& McInerney 2010). On the contrary Budin (2011) comments how actress Kaitlin Olsen discusses homebirth in the media in a positive way. The original article in question by Fawn (2010), presents Olsen’s stance on homebirth whereby she describes how she believes her body can birth without medical intervention. It is inspiring to see that some celebrities are using their status in the media to actively promote natural birth in environments other than the hospital. Likewise, journalist Sylvia Thompson from The Irish Times appears to actively promote midwifery-led care in Ireland. She also explores the benefits of midwifery-led care such as women-centred care (Thompson 2009) which is promoted by the governing body An Bord Altranais (ABA) (2010).
It is important that women understand that they have options other than conventional routine care as offered by hospitals. Women have a voice and most importantly- a choice (Edwards 2004). This choice, however, is located in the dominant system of obstetrics as highlighted by Murphy-Lawless (1998, p.23). This was also noted by Thompson (2009) where choice in Irish maternity care is described as a conveyor belt system. The oppressive obstetric-led system of Irish maternity care was notable in the HSE (2012) ‘whatsupmum’ website whereby options of places to give birth were limited to that of the hospital. The need for Irish women to have a choice for place of birth is acknowledged by Wayman (2010) as paramount for women. The imagery used in the videos largely promotes the hospital environment. This representation of care largely conflicts with Edward’s (2004) view that women are best taken care of outside the cold sterile hospital environment. Optimum care is outside the hospital with skilled midwives who focus on women centred care (Edwards 2004). By neglecting to share options with women other than obstetric led care, the ‘whatsupmum’ (HSE 2012) perhaps supports ideas circulating in the media, i.e that homebirth is not safe and that obstetric-led hospital care guarantees a safety net (Henderson 2000). Midwives have a responsibility to view pregnancy as a normal and healthy life event (ABA 2010).
A study by Torlon et al (2011) assessed the accuracy of information surrounding caesarean section in Brazilian women’s magazines. Reviewing 118 articles from 1988-2008 in Brazil (a country with one of the highest caesarean section (CS) rates worldwide) the authors found that 84 articles reported on at least one benefit of CS; while only one third of articles acknowledged the long term maternal and perinatal risks associated with CS. As women’s magazines are one of the most ubiquitous influential sources of information for women shaping their opinions on options for childbirth, midwives need to provide women with the evidently accurate facts. The articles reviewed by Torlon et al. (2011) exposed how portrayal of CS in the media is unbalanced and incomplete. However, limitations of the study include subjectivity in assessing the quality of the related articles. The authors highlighted how some women owed their choice to have a CS to a fear of the pain associated with a vaginal delivery. Women need to be given detail and balanced information about CS. It is important midwives inform women that CS is also associated with pain and that the recovery period is longer. This information appeared absent in the articles reviewed. NICE (2004) have ruled that in the absence of a genuine medical condition warranting CS; maternal request does not justify this option. Budin (2011) and Thompson (2009) discuss a positive account in the media of a woman’s experience of having a midwife and doula present for labour and birth. Factors such as continuity of care and continuous emotional support led to a satisfying, safe birth- factors which midwives can offer women (Budin 2011, Thompson 2009).
Begley et al. (2008b) notes it is common for the midwife to be referred to as a nurse in society, given the apparent lack of recognition to the profession. It is time that the “trust me, I’m a doctor” notion regarding safe maternity care is muted and that midwives’ roles as autonomous, accountable professionals is highlighted in the media (Wagner 2001, p.36). It is imperative that women understand the autonomous role of the midwife in relation to provision of maternity care for healthy women. The media’s representation of risk surveillance and obstetric-led care has generated discourse among some women that pregnancy and childbirth is best managed in a hospital under an obstetrician; which, as we know, is not what evidence suggests for the low risk woman. It is of upmost importance that women have a choice of where to give birth in Ireland and that choice is not limited to the hospital environment.
Implications for practice
Media representation has implications for practice, particularly if they are inaccurate. It creates confusion for women who are supposed to benefit from it. The debate around ideal body image during pregnancy creates uncomfortable feelings for women who do not fit into the acceptable parameters. This has the potential for influencing women’s care seeking behaviour. The idea that the hospital is the safest to give place to give birth gives superiority to the dominant obstetric risk approach to care while undermining the midwifery-social model making the midwives invisible. This raises the question as whose interest is being protected, that of the women or the profession? When the two model of care are in conflict, the care offered to the women will likely suffer.
Midwives should be cognisant of measures women may use to remain thin whilst pregnant, or lose weight rapidly in the postnatal period. Similarly, midwives should be aware of infant formula advertisements that may allude to the idea they are advocated by ‘experts’. I believe the fight between obstetrics and midwifery to protect and validate each profession needs review given that the overall goal of maternity care is to promote safe, women-centred care; regardless of care-giver or setting.
In addition, little is known about the reasons why some women opt to utilize information provided by the media over their healthcare professional. Such research may be beneficial in order to ascertain the reasons why, so to amend the current way information is offered to women from healthcare professionals.
The aim of this literature review was to explore the existing literature on media representation of pregnancy, childbirth and early motherhood on pregnant women and mothers. It would appear from the above review that exposure to media on the themes addressed has the potential to empower women’s decision making; or creates discourse which may be inaccurate. Based on this review, examples of inaccurate discourse influenced by the media include: women’s bodies should be thin in pregnancy, hospital as the safest place to give birth, midwives as inferior to obstetricians and breastfeeding is difficult. In relation to body-image, it would appear that there is an expectation set out by the media for the ideal image of pregnancy and early motherhood. Women are criticised for normal physiological adaptations to pregnancy, and are put under immense pressure to return to their pre pregnant -bodies in a short space of time.
It has been noted that women access mass media to complement information from other sources for example friends and family or antenatal classes. Due to sexualisation of breastfeeding in the past, there is social embarrassment attached to breastfeeding in public. This calls for a better representation of breastfeeding in the media in order to normalize and promote it. Midwives are in a better position to promote pregnancy as a normal event in a woman’s life, and they need to emphasise that physiological adaptations are necessary in the antenatal and postnatal period in order to ensure a healthy pregnancy and postnatal period (ABA 2010. Because the media presents obstetric-led hospital based care as safer and superior, the role of the midwife is often downplayed. Websites such as whatsupmum (HSE 2012) largely promote hospital based maternity care in Ireland and neglect to mention midwifery-led care or homebirth. The need for women to be aware of choice with regard to care giver and place of birth is paramount to enhance women’s experiences of maternity care. It is important that women are exposed to birth as a normal event without the dramatics that are often used in fictional television shows that tend to portray birth as risky or dangerous. The popularity of social media is of significance for midwives as a new form of communication in maternity services to offer information, support and advice on pregnancy, childbirth and early motherhood. It is therefore important that medical discourse surrounding hospital based obstetric-led care that is perhaps influenced by the media, is addressed in order to inform women of the evidence surrounding midwife-led care versus obstetric-led care, for example being the Birthplace Cohort Study (RCM) (2011) .